C A LIFORNIA HEALTHCARE FOUNDATION

Store-and-Forward Teledermatology Applications

Prepared for California He a l t h Ca r e Fo u n d a t i o n by University o f California, Da v i s De p a r t m e n t o f De r m a t o l o g y April W. Armstrong, M.D., director of teledermatology Steven W. Lin, M.D., clinical research fellow Fu-Tong Liu, M.D., Ph.D., professor and chair Christopher Sanders, clinical research analyst

Ce n t e r f o r He a l t h a n d Te ch n o l o g y Aron D. Farbstein, programmer II, George Z. Wu, technical manager Thomas S. Nesbitt, M.D., M.P.H., director, and executive associate dean, School of Medicine

December 2009 About the Authors The authors, all with the University of California, Davis, are: April W. Armstrong, M.D., director of teledermatology program, Department of Dermatology; Steven W. Lin, M.D., clinical research fellow, Department of Dermatology; Christopher Sanders, clinical research analyst, Department of Dermatology; Aron D. Farbstein, programmer II, Center for Health and Technology; George Z. Wu, technical manager, Center for Health and Technology; Fu-Tong Liu, M.D., Ph.D., professor and chair, Department of Dermatology; and Thomas S. Nesbitt, M.D., M.P.H., director, Center for Health and Technology, and executive associate dean, School of Medicine.

Acknowledgments The authors acknowledge the valuable input of Drs. John Bocachica, Marc Goldyne, Joseph Kvedar, Karen Edison, Hon Pak, Bernard Cohen, Nayla Idriss, and Noah Craft. They thank the members of the American Telemedicine Association Teledermatology Special Interest Group and the Telemedicine Task Force of the American Academy of Dermatology for their participation in this project. They also express appreciation to the technology teams at AFHCAN, Medweb, TeleDerm Solutions, and Second Opinion for communicating with the research team regarding technical evaluation aspects of the project.

About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org.

©2009 California HealthCare Foundation Contents

2 I. Executive Summary

3 II. Introduction

4 III. Store-and-Forward Teledermatology

5 IV. Evaluation Criteria

7 V.  Comparison of Store-and-Forward Applications Alaska Federal Health Care Network (AFHCAN) Medweb TeleDerm Solutions Second Opinion Evaluation Summary

13 VI. Application of Research Findings

15 VII. Conclusion

16 Endnotes I. Executive Summary

Teledermatology is t h e p r a c t i c e o f This report summarizes the key criteria for dermatology using communication technology. evaluating S&F applications. With input from In the United States, this method of facilitating experts in teledermatology, dermatologists at the dermatologic care has been used primarily to improve University of California, Davis (UCD) identified patient access in medically underserved and remote four major commercially available S&F applications communities.1, 2 in the United States. A multidisciplinary team Store-and-forward (S&F) teledermatology, then determined the key elements by which S&F the most common form of teledermatology, offers teledermatology applications should be appraised. several potential advantages over traditional, in-office UCD dermatologists and information technologists dermatologic care.3,4 It has the ability to lower the then evaluated each S&F application according to cost of dermatologic care, increase patient access, these criteria. Experienced teledermatologists with and facilitate medical education and training.5 – 9 But high case volumes were also interviewed regarding potential users can find it difficult to select an S&F their evaluation of the respective S&F applications. application appropriate to their specific needs Implementing an S&F teledermatology program is a sizeable undertaking for practitioners and health care organizations. Successful program implementation requires clear identification of goals, thorough understanding of an organization’s care delivery and business models, and a well-articulated, strategic implementation plan.10 There are several variables that can affect the selection of a particular S&F teledermatology application: characteristics of the practice, patient volume, the medical record filing system currently in use, and financial considerations.

2 | California He a l t h Ca r e Fo u n d a t i o n II. Introduction

Te l e m e d i c i n e — t h e u s e o f t e l e c o m m u n i c a t i o n s and information technologies to provide health care remotely — has the potential to improve health care by overcoming time and distance barriers and reducing costs. Given the near-universal use of the Internet, the increasing range of remote communication models, and the pressure to cut the cost of health care, the time may be ripe for telemedicine. Yet there are significant barriers to adopting telemedicine in health care systems of all sizes, including a lack of understanding about how to choose and implement available systems effectively. The California HealthCare Foundation commissioned the Department of Dermatology at the University of California, Davis (UCD) to explore how providers select an S&F teledermatology application and to evaluate the major S&F applications in the United States. A multi-disciplinary team of dermatologists, primary care providers, and information technologists was assembled to determine criteria for evaluating S&F teledermatology applications. Through a collaborative effort, the team identified evaluation criteria and performed an analysis of each application using the evaluation criteria and interviews with expert teledermatologists.

Store-and-Forward Teledermatology Applications | 3 III. Store-and-Forward Teledermatology

Th e r e a r e t h r e e m a j o r m o d e l s o f readily available than that required for real-time teledermatology delivery: S&F, live interactive, and teledermatology.2 On the other hand, the lack of the hybrid model. Among these models, S&F is the interaction between the dermatologist and the most commonly used; yet each model has advantages patient in the S&F modality is often perceived as and drawbacks.1 Selecting among these modalities a disadvantage. depends on the specific needs, preferences, and objectives of referral and consultant sites. Figure 1. S&F Teledermatology Consult Process The practice of S&F teledermatology entails the capture of still digital images and clinical information (e.g., history of present illness) and transmission of this information from referring providers to Primary care provider 1 sees patient dermatologists for asynchronous review. This with skin conditions. modality is similar to an email system in which users are not required to be simultaneously engaged at 2 their computers. Primary care provider or S&F teledermatology is an innovative, 2teledermatology coordinator takes technology-enabled method of providing specialist digital photographs of skin lesions. care to patients who live in medically underserved or remote areas. Patients may benefit from decreased travel time and costs associated with visiting a History and digital images 3 are securely transmitted dermatologist, as well as to improved access to to a dermatologist. dermatologic care.1 Referring providers in remote areas benefit from S&F teledermatology because they gain access to specialists’ opinions.2 Dermatologist reviews case Generally, an S&F teledermatology consult is 4and provides recommendations to the primary care provider. conducted as shown in Figure 1. S&F teledermatology differs in three major ways from live interactive teledermatology and the hybrid Source: University of California, Davis, Department of Dermatology. model. First, it is asynchronous, which saves the resources required to coordinate mutually agreeable appointments.2 As a result, some teledermatologists contend that S&F teledermatology consultations may be more efficient than real-time consults.2 In addition, the hardware required for S&F consultations is generally less expensive and more

4 | California He a l t h Ca r e Fo u n d a t i o n IV. Evaluation Criteria

Implementing a teledermatology p r o g r a m to estimate patient volume, hours necessary for is not easy. Despite the reported potential benefits teledermatology coordinators, reimbursement rates, of teledermatology, many programs have not equipment costs, and specialist compensation before flourished.9 Researchers have cited several reasons implementation. Among these factors, estimating why some programs are successful while others are patient volume and the number of hours necessary not. For example, S&F teledermatology programs for a teledermatology coordinator are the most have been successful in government organizations, challenging. Due to the natural ebb and flow of such as the Department of Defense, and in closed patient volume, hiring a part-time teledermatology health care systems, where the organization has coordinator or sharing the cost of a medical staff reasonable financial incentives to implement S&F member might be appropriate for clinics without teledermatology. In contrast, many other health care constant, high patient volumes. organizations have complex referral and authorization Finally, if the program does not have “buy processes, which may impede implementation of an in” from the organizational leaders and referring S&F program. Therefore, the initial steps in creating physicians, it likely will not flourish.10 Many referring a program are to evaluate how a program may meet physicians resist changes in their practice patterns, the patient demand for specialist care and how and some may be especially skeptical of programs such a program integrates into the existing health that require their additional involvement (such as care structure.1, 9 A thorough understanding of the communicating with patients regarding a specialist’s organization’s system of delivering care, its business recommendations.) Thus, it is critical to identify model, legal and regulatory issues, and community referring physicians who will help champion the S&F needs are also important to implementing a program within a referral clinic. successful program.1, 9 Despite these challenges, multiple programs have Some programs have not been successful because been sustainable and successful in the United States. the core purpose of teledermatology — increasing A critical factor in that success is the selection of an access to care — has been misunderstood. appropriate S&F teledermatology application. But Teledermatology programs are generally embraced there are currently no established criteria or tested in medically underserved areas, where the approaches for evaluating available S&F applications, community would otherwise lack access to specialty and there are no studies that have compared the care. However, if there is sufficient access to local major S&F teledermatology applications. dermatologists, people usually have traditional face- The investigators in this study identified to-face care. four major S&F applications available in the It is important to calculate the resources United States: AFHCAN, Medweb, TeleDerm required to implement an S&F program during the Solutions, and Second Opinion. With input from planning stages; failure to do so could result in a teledermatologists from the American Telemedicine non-sustainable operation. Program directors need Association and the American Academy of

Store-and-Forward Teledermatology Applications | 5 Dermatology, a multidisciplinary team consisting of dermatologists, primary care physicians, and information technologists worked to develop a set of evaluation criteria that can be used to assess an S&F teledermatology application (Table 1).

Table 1. Evaluation Criteria for Store-and-Forward Teledermatology Applications

Evaluation Criteria Description System Requirements Technical resources required to operate the program. Ability to run on a local computer versus web accessibility only.

HIPAA Compliance, HIPAA compliance with secure storage, transmission, and access. Security, and Privacy

Information Sharing Ability to store and transmit digital images, clinical history, and consultant and Storage recommendations in an organized and searchable fashion.

User Interface User-friendliness and intuitiveness of the application. Upload speed for digital images.

Compatibility Integration with existing EMR systems and applications. Ability to interface with standard imaging communication formats such as DICOM and PACS.

Scalability Ability to fit into organizations of various types and sizes.

Billing Ability to upload, capture, and/or process billing information directly to a third party payer.

Cost License, server, and user costs.

DICOM: Digital Imaging and Communications in Medicine EMR: Electronic Medical Records HIPAA: Health Insurance Portability and Accountability Act PACS: Picture Archiving and Communication System

6 | California He a l t h Ca r e Fo u n d a t i o n V. Comparison of Store-and-Forward Applications

Ea ch o f t h e a p p l i c at i o n s h a s u n i q u e or by AFHCAN. In the latter case, AMD Global technical and practical considerations: Telemedicine, Inc. can host tConsult Server under a secure Application Service Provider (ASP) model Alaska Federal Health Care Network starting at $1,000 per month. (AFHCAN) Since its inception in 1998, AFHCAN has facilitated Expert Teledermatologist Perspective telemedicine encounters at more than 273 sites An expert teledermatologist has used AFHCAN spanning six states and three countries. Referrals are for seven years and consults on at least 20 cases per created using tConsult Cart, a locally-installed client day using tConsult Web. Approximately 60 percent application. Patient information is transmitted to of this teledermatologist’s referrals come from consultants via a Web service, tConsult Web, which rural clinics, 30 percent from rural hospitals, and is Internet-accessible via Internet Explorer or Firefox 10 percent from non-rural hospitals. This expert said: and does not require software installation or plug-in ◾◾ For a Web-based application with an intuitive downloads. interface, tConsult Web would appeal to The tConsult Web interface is arranged similarly new users who may not be technologically to commonly used email applications. All case knowledgeable. activity is synchronized between users who have previously accessed the case. Comments from the ◾◾ tConsult Web’s strengths include large, color- referring and consulting physicians are organized and coded icons, clearly labeled data entry fields, the presented as a chronological dialogue. simplicity of the search features, and its overall Most options, such as “Add Comment,” “Attach organization and layout. Document,” and “View Activity,” are easily selected ◾◾ AFHCAN 4.9 could be improved by creating the as hyperlinks. Files and images are simply uploaded ability to interface with electronic medical records from either the user’s hard drive or captured from and to submit billing information to third-party peripheral devices. There are several other user- payers. friendly functions, including detailed search options, a custom form creation tool, capability to print the ◾◾ tConsult Web is easy to use, provides an intuitive case reports, and the ability to create quick lists of layout and is efficient at handling a high volume patients or providers. of consultations. Pictures are viewed within a separate “Image Viewer” window that provides various options Medweb including zoom, contrast and brightness, and save Medweb has been in operation for more than and/or print. 20 years. It was originally designed for radiology tConsult Web can be maintained either by but is now also used in a number of other medical the site’s own information technology department specialties, including dermatology. Medweb 7.0.0

Store-and-Forward Teledermatology Applications | 7 is entirely Web-based. The client software is an Expert Teledermatologist Perspective Internet Explorer plug-in that can be installed over An expert teledermatologist has used Medweb since the Internet and can be installed and used on any PC January 2009 and has not previously used any other with a Windows 2000 or higher operating system teledermatology applications. This teledermatologist and Internet access. consults on an average of 20 cases a month using Referring providers create cases by entering Medweb. All the cases are from free-care clinic information into either (1) a “highly structured” referrals. This expert said: form containing multiple check boxes and radio ◾◾ Among Medweb’s (7.0.0) various features, the buttons or (2) a “semi-structured” form with more range of image viewer features and the concise free text-entry fields. display of the clinical data within a consult Both types of data-entry forms are request are of particular value. comprehensive, and users do not have the option to create customized data-entry forms. Images can be ◾◾ Medweb 7.0.0 can run only on a Windows uploaded from the user’s hard drive or captured from operating system. The lack of Mac platform peripheral devices. Each image in Medweb 7.0.0 compatibility is unfortunate but can be addressed has an associated number, which can be dragged to by installing a Windows-based operating system a body diagram to illustrate the anatomic location onto a Mac computer. involved in the consultation. This is a useful feature ◾◾ Medweb could be improved by using simpler for matching a skin image with a body area. user-interface functions to navigate and edit The consultants’ interface provides a list of cases consultation reports. However, Medweb (7.0.0) in queue with a color-coding system that indicates has proven its ability to efficiently facilitate each case’s level of urgency. While the referring consultations. providers enter clinical information in discrete fields, the dermatology consultants receive the clinical information in a single, reformatted display TeleDerm Solutions that is easy to view. This useful feature provides First offered in 2001, TeleDerm Solutions is the consultants with a consolidated view of relevant only S&F application studied for this report that clinical information. When responding to cases, was specifically designed for dermatology. The the consultants can use the “patient education file” current version is an entirely Web-based application. feature that allows them to attach a .doc, .xls, or .pdf Users can securely create and access consults from a file to the referring provider. These files can include mainstream Internet browser. detailed instructions for the referring provider or Referring providers create consults by entering educational material for the patients. information into “Complaint” tabs. The relevant Medweb 7.0.0 offers a robust image-viewing clinical information associated with each complaint feature for consulting physicians. It provides is populated by using drop-down menus with an numerous ways to annotate and manipulate image option to enter free text information. Images must be properties (e.g., zooming, labeling, rotating), and it uploaded from the computer’s hard drive and cannot has a virtual magnifying glass that can be dragged be directly imported into the program from external around the image for closer inspection. sources, such as a digital camera.

8 | California He a l t h Ca r e Fo u n d a t i o n The consulting dermatologists’ “Home Page” ◾◾ TeleDerm Solutions 2.0 has a simple design provides users with an overview of all consults, and its ease of use would be attractive to many organized according to their status. For example, the new users. It is also the only application that consultants can view “Pending Consults” or “Answer can incorporate dermatology trainees in the New Consults,” all sorted by date. consultation workflow, allowing the attending The Java-based image viewer in TeleDerm dermatologists to engage and supervise trainees, Solutions displays the image after several seconds. such as dermatology residents, in the consultative It contains basic functions for image manipulation, process. including magnification, inverting, zooming, ◾◾ The application could be improved by enabling flipping, and fit to window. Only one image can be faster image access and allowing more than one loaded at a time. image to be viewed at a time in the image viewer. As a teledermatology-specific application, Like the other S&F applications evaluated in TeleDerm Solutions 2.0 contains a large database this report, TeleDerm Solutions 2.0 could also of dermatology-specific templates in five categories: be enhanced by through integration with billing “Diagnosis,” “Tests,” “Procedures,” “Medications,” functions. and “Patient Information.” The use of these pre- written templates potentially could decrease the time required to answer a consult. For example, the Second Opinion user will find a 906-word “Patient Information” Second Opinion was introduced in 1994 and is document on allergic contact dermatitis, which can installed at over 1,800 sites internationally. Second be included in a consultant’s response. Users cannot Opinion was designed to be installed locally by users modify existing templates for future use or create and is not inherently Web-based. The application their own templates. However, once the template can be accessed via the Web using remote access is imported into the entry field for a patient, technologies such as CITRIX and offers a Web the teledermatologist can then edit the text to Access module to allow data access through the individualize the response for each patient. Internet. The current version, Second Opinion 7.07, Expert Teledermatologist Perspective typically uses local drives or servers to store the Two teledermatologists with extensive experience clinical information. However, it can be configured using TeleDerm Solutions 2.0 were interviewed. One to store patient information in a centralized location has used the application for eight years, responds to allow providers to access information about a large to approximately 450 cases per month and has a number of patients. payer mix entirely within the U.S. Department of Referring providers create case content by using a Defense. The other has used the application for two combination of text documents, database forms, and years, consults on an average of 30 cases per month, image capture methods available in Second Opinion and has a payer mix of around 75 percent private 7.07. The application has a set of standardized insurance, 10 percent self-pay, and 20 percent pro referral and consultation forms suitable for most bono consultations. These experts indicated: medical specialties. It also offers a number of optional features at no additional cost to users interested

Store-and-Forward Teledermatology Applications | 9 in customizing their own documents, such as the Expert Teledermatologist Perspective Developer’s Tool Kit, Custom Form Designer, and The teledermatologist experienced with Second Custom Report Writer. Completed referrals are sent Opinion has used the application for seven years and as encrypted email attachments to consultants. consults on an average of 26 cases per month. The The consultants are required to install another expert said: program, Second Opinion Professional Expert It is best to download referrals directly to the Edition 7.0.4, to view and respond to consults, local hard drive. The patient file organization with and every consultant must register with the vendor subfolders within a patient’s file, similar to the for tracking purposes. “Expert Edition” is free to organization of a physical patient file, is good. consultants but must be purchased by the referring The image viewer, which displays multiple images sites. at the same time, is versatile, efficient, and robust. The consultant responds to a referral by typing The basic consultation fields, which allow text from free text into a basic form that contains three other Word documents to be copied and pasted fields: “Consultation,” “Recommended Treatment directly, are useful. As with other S&F applications Plan,” and “Recommended Follow Up/Additional reviewed here, Second Opinion 7.07 can be Comment.” Consultants also have the option of improved by creating integrated billing functions. customizing documents. Completed forms can be saved as Word documents for printing, faxing, Evaluation Summary emailing, and postal mailing. Word documents sent Table 2 on the following pages summarizes the by email are password-protected to ensure security. evaluations of the major S&F applications according All of a patient’s clinical information is to the criteria. grouped into different levels of folders. A follow- up consultation request on a returning patient is automatically saved in that patient’s file and sorted by date. This makes it possible for the referring provider and the consultant to easily view previous consultations on the same patient. Second Opinion’s image viewer is intuitive and versatile. It can play media clips and display still images, forms, and other documents. Multiple pictures can be viewed within a single window. Simply dragging a picture from the patient folder into the image viewer allows the user to compare several images side by side. Users can also annotate the images within the Image Viewer.

10 | California He a l t h Ca r e Fo u n d a t i o n Table 2. Evaluation Summary of Major Store-and-Forward Teledermatology Applications

Evaluation TeleDerm Criteria Description AFHCAN Medweb Solutions Second Opinion System Resources required Referral sites require PC with Microsoft Pentium class PC PC with Microsoft Requirements to operate the installation of a local PC Windows 2000 with 500MB RAM Windows XP and program. Ability application. Consultants (or higher) and an running Internet Microsoft Office. Client to run on a local access cases via a Internet connection Explorer 5 or later. software is currently computer versus Web-based application running Internet compatible only with Web accessibility. using Internet Explorer Explorer 5.5 Service Microsoft Windows XP. or Firefox. Pack 2 or later. Accessible via the Web using terminal services technology such as CITRIX. Second Opinion also has a WebAccess product not evaluated here.

HIPAA HIPAA compliance Data is encrypted with Data is encrypted Data transfer Local client stores Compliance, with secure storage, SSL. Cases can only be with SSL. Patient encrypted via HTTPS patient data in an Security, and transmission, and sent to recipients who information record and SSL. Hosted encrypted (128-bit) Privacy access. are preconfigured within activity is tracked and Service is from a file that is sent to the the AFHCAN system. can be monitored Tier-1 data center consultant as an email Patient information by a network approved by the VA. attachment. Password record activity is administrator. Once While creating a protection prevents tracked. All users can files are uploaded to case, users must unauthorized access. view detailed reports. a case, they cannot reconfirm login Information can also be removed or credentials at several be sent in real-time altered. stages. by utilizing a network connection, thus eliminating need for file transfer via email.

Information Ability to store Images can be Images can be Images can be Database is installed Sharing and and transmit uploaded from file or uploaded from file uploaded from file locally by default but Storage digital images, captured from medical or captured from or captured from can be configured clinical history, peripherals. Patient data medical peripherals. medical peripherals. for access from a and consultant is stored in a central Patient data is stored Patient data is stored centralized location. recommendations location where it is in a central location in a central location Images are uploaded in an organized and easily accessible. where it is easily where it is easily from file. searchable fashion. accessible. accessible.

User Degree to which Features intuitive Patient data is Intuitive workflow. The user interface Interface the application is interface with large entered in a A database of utilizes standard user-friendly and clickable buttons tabbed form. dermatology-specific Microsoft icons. intuitive. Upload (suitable for touch Provides a library of templates enhances Patient information is speed for digital screen). Web interface customizable forms. efficiency. organized in an intuitive images. features email-like fashion. layout similar to Microsoft Outlook. Patient case data can be entered on user-customizable forms.

AFHCAN: Alaska Federal Health Care Access Network PC: Personal Computer HIPAA: Health Insurance Portability and Accountability Act RAM: Random Access Memory SSL: Secure Sockets Layer VA: Veterans Administration HTTPS: Hypertext Transfer Protocol Secure

Store-and-Forward Teledermatology Applications | 11 Evaluation TeleDerm Criteria Description AFHCAN Medweb Solutions Second Opinion Compatibility Integration with Limited support for Supports PACS Incompatible Does not support existing EMR PACS and DICOM. and DICOM. HL7 with PACS and “out of box” HL7 or systems and Integration with existing import/export is DICOM. HL7 PACS compatibility. applications. Ability PACS and DICOM not supported. compatibility requires Integration with to interface with requires customization Integration with HL7 customization. existing EMR and standard imaging with additional fee. is available for an Compatible with PACS and DICOM communication Does not currently additional fee. Internet Explorer 5.0 support are available formats such as support HL7. Version or greater for additional fees. DICOM and PACS. 5.0, released in 2009, This application is offers limited HL7 standards-based and support. can be integrated with third-party reporting software (e.g., Crystal Reports, Microsoft Access, Visual Foxpro, etc.)

Scalability Ability to work in Scalable Scalable Scalable Additional configuration organizations of and resources may various sizes and be required for large functions. deployments.

Billing Ability to upload, Creates a billing report Has embedded Billing integration Billing integration capture, and/ form that can be sent to ICD-9 and CPT requires requires customization. or process billing any system. code libraries. The customization. information directly uploading process to to a third party another system has payer. to be defined.

Cost License, server, and Distributed worldwide $17,500 for the $3,500 “start-up Referral sites pay an user costs. by AMD Global server software fee” per location, average of $2,500 Telemedicine, Inc. and hardware which pays for for the basic version/ including one TeleDerm staff network node and • tConsult Server: Perpetual Use License practice application to provide on-site $5,000 per site for a ranges from $2,500 to (dermatology). training. Thereafter, full version of Second $20,000 depending on Mandatory $3,000 consulting Opinion Professional. size of deployment. installation fee dermatologists pay Expert Edition is free and mandatory a $4 transaction fee for consultants. • tConsult PC Client: $3,000 training fee. per consult. Referral Each referral site pays Mandatory two year sites pay an annual $3,700 for a Perpetual and beyond service maintenance fee of Use License. fee of $3,000. $500. • tConsult Web Client: This Internet Explorer- based application is free of charge for consulting physicians.

CPT: Current Procedural Terminology DICOM: Digital Imaging and Communications in Medicine EMR: Electronic Medical Records HL7: Health Level Seven ICD-9: International Classification of Diseases, Ninth Revision PACS: Picture Archiving and Communication System

12 | California He a l t h Ca r e Fo u n d a t i o n VI. Application of Research Findings

Teledermatology is o n e o f t h e m o s t When decisionmakers are ready to acquire rapidly expanding areas of telemedicine in the United an S&F teledermatology application, they States.11,12 Among the different teledermatology should perform an assessment of the existing delivery modalities, S&F teledermatology has information technology (IT) capabilities within significant potential to provide timely and low-cost their organization. For this assessment, they could dermatologic care to medically underserved and use a tailored version of the criteria from Table 1. remote communities.9, 10, 13 – 15 One of the first steps Important elements of the IT needs assessment in establishing an S&F teledermatology program is include understanding existing system requirements, the selection of an intuitive, secure, and affordable organizational policies regarding HIPAA compliance, application. secure storage, transmission, and access of In establishing any S&F teledermatology medical records and clinical images, integration of program, the decisionmakers should analyze how telemedicine data with existing EMR, and existence a teledermatology program fits into the existing of electronic billing mechanisms. organizational structure operationally, financially, and Once the capabilities of the existing IT structure culturally.10 Specifically, it will be necessary to: have been assessed, the decisionmakers should compare their organizational IT capabilities with ◾◾ Understand specific ways in which an S&F that of the existing S&F applications to determine teledermatology program fulfills needs or optimal fit. The existing S&F applications should demands within a particular health care be evaluated against the criteria outlined in Table organization, such as increasing patient access 1 (Evaluation Criteria for Store-and-Forward or reducing health care costs; Teledermatology Applications). The decision will ◾◾ Identify alternatives to telemedicine that could depend on the organization’s patient volume, help fulfill the same needs or demands; reimbursement and financial system, and user preferences. ◾◾ Compare the telemedicine reimbursement The four S&F teledermatology applications structure with that of other health care delivery evaluated in this report are mature and well- models; developed products. Their organization and features ◾◾ Define the current workflow and the cultural differ widely. Each application can handle the basic perception of telemedicine programs within necessities of teledermatology consultations, but all the organization; four applications lack good integration with existing electronic medical records systems and billing ◾◾ Determine resources of the organization to features. In summary: support S&F teledermatology; and ◾◾ AFHCAN 4.9 has a simple interface with large ◾◾ Identify potential teledermatology “champions” buttons and clearly labeled data entry fields. It within the organization. facilitates consultations through an interface

Store-and-Forward Teledermatology Applications | 13 that is similar to email, making learning the folders and subfolders. The program has the application easy for most users. Navigation within ability to recognize return patients and collates a consult is simple, supported by self-explanatory all visits belonging to the same patient into that links. It requires both local installation (tConsult patient’s file. Second Opinion’s organization Cart) and use of a Web interface (tConsult Web) scheme makes it particularly useful for sites that to facilitate consultations. Consultants have free require follow-up S&F consultations on the access to tConsult Web. AFHCAN 4.9 could be same patients. The program also has a robust and improved by allowing users to remove uploaded versatile image viewer that allows multiple images documents prior to transmitting a consult. to be seen simultaneously.

◾◾ Medweb 7.0.0 is entirely Web-based and requires plug-in download and installation. It has broad platform compatibility, as it can be used with Windows, Linux, or Apple operating systems. Medweb 7.0.0 has rich image display and editing features in its image viewer, allowing users to perform advanced image manipulation and annotation. Patient information is automatically reformatted into a concise display for consultants. The “Patient Education File” allows users to upload documents but could be improved by allowing users to create customized templates.

◾◾ TeleDerm Solutions 2.0 was uniquely designed for facilitating S&F dermatology consultations. It is entirely Web-based. Some users may appreciate its pre-designed, dermatology-specific templates. TeleDerm Solutions 2.0 is the only application that allows trainee involvement in the consultative process with supervision from attending dermatologists. TeleDerm Solutions can be improved by updating some technology such as auto-fill of data entry fields and allowing more than one image to be viewed simultaneously.

◾◾ Second Opinion is not inherently Web-based; it uses local drives or servers to store clinical information. Some users may prefer downloading information locally because this would allow them to work offline. This application is highly structured, organizing patient information into

14 | California He a l t h Ca r e Fo u n d a t i o n VII. Conclusion

Al l f o u r a p p l i c at i o n s e v a l u a t e d are capable of facilitating S&F dermatological consultations. The development of S&F teledermatology applications in the future should be focused on: reducing the cost of the applications, simplifying user interface, increased compatibility and integration with electronic medical records systems, and development of fully integrated billing capability. With continuing advances in the field of S&F teledermatology, comparative analysis of the existing S&F applications is essential to inform potential users and encourage progress in the development of S&F teledermatology applications.

Store-and-Forward Teledermatology Applications | 15 Endnotes

1. Pak, H., K. Edison, and J. Whited. Teledermatology: 10. Pak, H.S. “Implementing a teledermatology programme.” A User’s Guide. 1st ed: Cambridge Press; 2008. Journal of Telemedicine and Telecare. 2005;11(6):285 – 293. 2. Pak, H. and G. Burg. Store-and-Forward Teledermatology. 11. Krupinski, E., A. Burdick, H. Pak, et al. “American May 30, 2008, emedicine.medscape.com/article/ Telemedicine Association’s Practice Guidelines for 1130993-overview. Last accessed July 22, 2009. Teledermatology.” Telemedicine Journal and E-health. April 2008;14(3):289 – 302. 3. Whited, J.D. “Teledermatology research review.” International Journal of Dermatology. March 12. Kvedar, J.C., R.A. Edwards, E.R. Menn, et al. “The 2006;45(3):220 – 229. substitution of digital images for dermatologic physical examination.” Archives of Dermatology. February 4. Eminovic, N., N.F. de Keizer, P.J. Bindels, and A. 1997;133(2):161–167. Hasman. “Maturity of teledermatology evaluation research: a systematic literature review.” British Journal of 13. Edison, K.E., D.S. Ward, J.A. Dyer, W. Lane, L. Chance, Dermatology. March 2007;156(3):412 – 419. and L.L. Hicks. Diagnosis, diagnostic confidence, and management concordance in live-interactive and store- 5. Lopez, A.M., D. Avery, E. Krupinski, S. Lazarus, and and-forward teledermatology compared to in-person R.S. Weinstein. “Increasing access to care via tele-health: examination. Telemedicine Journal and E-health. the Arizona experience.” Journal of Ambulatory Care November 2008;14(9):889 – 895. Management. January – March 2005;28(1):16 – 23. 14. Massone, C., E.M. Wurm, R. Hofmann-Wellenhof, 6. Whited, J.D., S. Datta, R.P. Hall, et al. “An economic and H.P. Soyer. Teledermatology: an update. Seminars analysis of a store and forward teledermatology consult in Cutaneous Medicine and Surgery. March 2008;27(1): system.” Telemedicine Journal and E-health. Winter 101–105. 2003;9(4):351 – 360. 15. Moreno-Ramirez, D., L. Ferrandiz, A. Nieto-Garcia, et al. 7. Williams, C.M., I. Kedar, L. Smith, H.A. Brandling- “Store-and-forward teledermatology in skin cancer triage: Bennett, N. Lugn, and J.C. Kvedar. “Teledermatology experience and evaluation of 2009 teleconsultations.” education for internal medicine residents.” Journal of the Archives of Dermatology. April 2007;143(4):479 – 484. American Academy of Dermatology. June 2005;52(6): 1098 – 1099. 8. Pak, H., C.A. Triplett, J.H. Lindquist, S.C. Grambow, and J.D. Whited. “Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care.” Journal of Telemedicine and Telecare. 2007;13(1):26 – 30. 9. Armstrong, A.W., D.J. Dorer, N.E. Lugn, and J.C. Kvedar. “Economic evaluation of interactive teledermatology compared with conventional care.” Telemedicine Journal and E-health. April 2007;13(2): 91 – 99.

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